CSP009412_Contract_REV.pdf

Index No.: BWC007

Eff. Date: 07/01/25

STATE OF OHIO

DEPARTMENT OF ADMINISTRATIVE SERVICES

GENERAL SERVICES DIVISION

OFFICE OF PROCUREMENT SERVICES

4200 SURFACE ROAD, COLUMBUS, OH 43228-1395

MANDATORY USE CONTRACT FOR: OHIO BUREAU OF WORKERS’ COMPENSATION (BWC) INDEPENDENT MEDICAL

EXAMINATIONS FOR THE BENEFIT OF OHIO’S WORKERS RESIDING OUT OF STATE

CONTRACT NUMBER: CSP009412 EFFECTIVE DATES: 07/01/22 TO 06/30/25

* Renewal through 12/31/25

The Department of Administrative Services has accepted Proposals submitted in response to Request for Proposal (RFP) No.

SRC0000002682 that opened on 05/04/22. The evaluation of the Proposal responses has been completed. The Offeror listed herein has been determined to be the highest ranking Offeror and has been awarded a Contract for the services listed. The respective Proposal response including, Contract Terms & Conditions, any Proposal amendment, special Contract Terms & Conditions, specifications, pricing schedules and any attachments incorporated by reference and accepted by DAS become a part of this Services Contract.

This Requirements Contract is effective beginning and ending on the dates noted above unless, prior to the expiration date, the Contract is renewed, terminated, or cancelled in accordance with the Contract Terms and Conditions.

This Requirements Contract is available to the Ohio Bureau of Workers’ Compensation (BWC) as applicable.

The agency is eligible to make purchases of the contracted services in any amount and at any time as determined by the agency. The State makes no representation or guarantee that department will purchase the volume of services as advertised in the Request for Proposal.

This Requirements Contract and any Amendments thereto are available from the DAS Web site at the following address:

https://procure.ohio.gov/

*Indicates mutual renewal for six months, effective 7/1/25.

Eff. Date: 07/01/22 Page No. 2

MUTUALLY AGREED TO MODIFICATIONS TO THE CONTRACT:

1. Best and Final Offer Letter – response dated 06/13/22

2. Affirmation and Disclosure Form – response dated 04/22/22

Eff. Date: 07/01/22 Page No. 3

COST SUMMARY

RFP for OHIO BUREAU OF WORKERS’ COMPENSATION (BWC) INDEPENDENT MEDICAL EXAMINATIONS FOR

THE BENEFIT OF OHIO’S WORKERS RESIDING OUT OF STATE

RFP NO.: CSP009412

UNSPSC CATEGORY CODE: 85101500

DESCRIPTION

COST

TOTAL REMIBURSEMENT CHARGE PER C-92 EXAMINATION $ 925.00 EA

TOTAL REMIBURSEMENT CHARGE PER ALL OTHER INDEPENDENT MEDICAL

EXAMINATION $ 950.00 EA

NO SHOW / CANCELLATION FEE $ 250.00 EA

ADDENDUMS $ 150.00 EA

INTERPRETER FEE BWC RATE SCHEDULE

EXCESSIVE MEDICAL FEE NO ADDITIONAL

CHARGE

CONTRACTOR INDEX

CONTRACTOR AND TERMS: BID CONTRACT NO.: CSP009412

0000007826 Medical Evaluators 28370 Kensington Lane, Suite B Perrysburg, OH 43551

TERMS: Net 30 Days

CONTRACTOR’S CONTACT: Michael Rumman

Telephone: (419) 874-9101 ext. 6314 Toll Free: (888) 874-9101 Fax: (419) 874-2055 Email: MRumman@medicalevaluators.com mailto:MRumman@medicalevaluators.com

Eff. Date: 07/01/25 Page No. 4

SUMMARY OF AMENDMENTS

Amendment

Number Effective

Date Description

1 07/01/25

This amendment is issued to notify that as a result of mutual agreement between the State of Ohio and the Contractor, this contract is renewed for an additional six months, effective 07/01/25 through 12/31/25. All other prices, terms and conditions remain unchanged.